2019 Utah Women's Health Review

The Utah Women's Health Review The Center of Excellence in Women's Health UNIVERSITY OF UTAH Masthead Volume 1 Number 1 May 2019 Editor-in-Chief Jessica N. Sanders, PhD, MSPH Executive Editors Kathleen B. Digre, MD Michael Varner, MD Susan Schulman, MAT CCRA Center of Excellence Coordinator Leanne Johnston Staff Article Editor Medha Gho Editorial Board Brenda Ralls Caren Frost Sara Simonsen Lori Gawron Bethany Everett Nicole Mihalopoulos Karen Schliep Library Support Anne Morrow Allyson Roylance Table of Contents Page 3 Letter from the Editor Healthcare Coverage and Access (HCA) Rural-Urban Disparities in Health Outcomes and Access to Care among Women in Utah Oral Health Care and Accessibility in Utah 5 14 Occupational and Economic Health (OCH) Intergenerational Poverty, Women and Children's Health 19 Environmental Health (EH) The Impact of Living at Altitude on Depression and Antidepressant Function in Utah Women: The Need for Novel Antidepressants 23 Sexual and Reproductive Health (SRH) Sexual Violence in Utah: The Relationship between Sexual Education and Sexual Violence 33 Cost of Sexual Violence 37 Perinatal Health (PH) Data Snapshot: Postpartum Depression 42 Breastfeeding and Mothers Own Milk is Best for Babies Breastfeeding Protects Mothers Milk Banking 52 55 58 Adolescent Health (AH) Data Snapshot: Adolescent Pregnancy Potential Anorexia among Adolescent Girls in Utah A Complex Web: Exposure to Domestic Violence, Aggressive Behaviors and Suicidality in Utah Adolescents The Utah Women's health Review 62 67 71 1 Screening and Disease (SD) Arthritis in Utah: Significant Differences for Women 77 Substance Use and Misuse (SUM) Select Alcohol-Attributable Emergency Department Visits and Inpatient Hospitalizations for Women 18-64 Years of Age Health Disparities in Special Populations (HDSP) 82 Women with Disabilities: An Important Health Disparity Population 88 Women's Health in Utah's Homeless Population 92 Sexual Minority Women's Health in Utah 95 General Articles (GA) Food insecurity & 5 Fruits & Vegetables Secondary data analysis of non-communicable diseases among adult female refugees arriving in Utah between 01/01/2012 and 12/31/2015 100 105 General State Health (GSH) Voting and Civic Engagement Among Utah Women 111 Utah Women and STEM 115 The Status of Women in Utah Politics: Congress, Statewide Executive Offices, and the State Legislature 120 The Status of Women in Utah Politics: Counties, Mayors, City Councils, and Boards of Education 128 Labor Force Participation Among Utah Women 137 2 The Utah Women's health Review Letter from the Editor Foreword that thinking of health in these multiple dimensions more accurately portrays the women's health challenges in public health. Executive Summary The University of Utah's Center of Excellence in Women's Health, in collaboration with the Utah Department of Health and the Utah Women's Health Coalition, has prepared an interdisciplinary publication devoted to Women's Health in Utah-The Utah Women's Health Review. This review represents an overview of health situations and opportunities for improvement in community health in Utah. The Utah Women's Health Review is an opportunity to highlight how far we have come in the last decade, since the Women's Health in Utah update was last published (http://healthsciences.utah.edu/ coe-womens-health/docs/coe-supplement-vol12. pdf), and also to serve as a forum for updates. This review also sheds light on gender differences and the areas where gender disparities continue to exist, and brings to light new and unresolved health concerns that need to be addressed. In this publication we have thoughtfully considered the intersection of physical and reproductive health, social health, emotional health, occupational and financial health, environmental health, intellectual health and spiritual health. The goal of this publication is to update knowledge surrounding women's health issues in our Utah community and beyond, as well as to create a tool that can be used to improve health for years to come and to serve as an open access home for publishing region-specific research. The Utah Women's Health Review also serves as a model for other Academic institutions and states to bring together interdisciplinary researchers, public health practitioners and women's health advocates to collaborate on a body of work that focuses on regional health issues. The broad spectrum of articles highlights the reality that health is more than one dimension-and Center of Excellence in Women's Health The Center for Excellence in Women's Health (CoE) is a multidisciplinary group focused on enhancing overall health and wellness for women. We are founded on the 5 pillars of community outreach, clinical care, research, education and leadership development. Our goal is to empower women of all ages with the knowledge to improve their health and the health of their families. The work of the CoE is based on: •Respect, caring, compassion, and integrity •Being non-competitive, non-hierarchical, and collaborative •Evidence-based practices We are supported in part by the Department of Obstetrics and Gynecology, the Office of the Vice President for Health Sciences, the Center for Clinical and Translational Science, the Office of Health Equity and Inclusion, DHHS Office on Women's Health, and the Office of Research on Women's Health. This review has been made possible in part by the Educational Resource Development Council at the University of Utah. The 7 Domains of Women's Health Everything we do is based on our philosophy that health is not just physical health, but also encompasses psychological/emotional, environmental, sociocultural, intellectual, economic, and spiritual - an approach we sum up as "The 7 Domains of Health". We promote these domains through information, research, education, outreach programs and clinical care. The COE provides a great opportunity for people with a wide range of philosophies to network and share and develop innovative projects together. The Utah Women's health Review 3 HEALTHCARE COVERAGE AND ACCESS (ACA) 4 The Utah Women's health Review Rural-Urban Disparities in Health Outcomes and Access to Care among Women in Utah Matt McCullough/ Utah Department of Health Office of Primary Care and Rural Health Abstract ` Objectives: The aim of this research project is to enhance understanding of the current rural-urban disparities in health outcomes among women in Utah. Methods: Percentages, confidence intervals and standard errors for fifteen health outcomes were calculated using age-adjusted data from the Utah Behavioral Risk Factor Surveillance System in order to compare rates for women in 63 rural, urban and frontier areas. Results: Women in rural areas had lower (better) percentages in all eight of the outcomes relating to general physical and mental health, as well as chronic conditions. Women in rural areas had higher (worse) percentages in all seven of the outcomes representing access to care and preventive services. Frontier areas had higher (worse) percentages than both rural and urban areas in eleven of the fifteen outcomes; five of them were significantly higher. Conclusion: Women in frontier areas in Utah have considerable challenges with both access to health care and preventive services, as well as general physical and mental health and chronic conditions. Women living in rural areas continue to struggle with access to care and preventive services, but have lower rates than urban areas in terms of a number of outcomes. Introduction The purpose of this research is to examine the rural-urban disparities in health outcomes among women in Utah. Urban, rural and frontier areas are considered in our analysis. Urban areas are classified as having a population of over one hundred people per square mile and make up only 5% of the land area in the State, although they contain approximately 75.5% of the total population. Rural areas are classified as having a population of six to ninety-nine people per square mile, make up 40% of the land area in the state of Utah and contain 21% of the population. Frontier areas have fewer than six people per square mile and cover 55% of the state but only contain 3.5% of the total population. A majority, 801,081 (80%), of women 18 and older reside in urban counties in Utah, while the remaining 206,426 women (20%) reside in the rural and frontier counties. Health disparities are defined as the differences in care experienced by one population compared to another population (Agency for Healthcare Research and Quality, 2010). The reason dispar- ities exist among populations are complex and may affect access, quality of care and outcomes (Egede & Bosworth, 2008; Institute of Medicine, 2002). Comparisons between health outcomes and disparities among different genders, races, ethnicities, and socioeconomic situations are common in health assessments; however, disparities by geographic regions may also exist. Poverty and access to care are two of the main reasons that disparities exist between women in rural and urban areas. Level of education, transportation challenges and adequate health insurance are also contributing factors. Lack of financial stability negatively affects access to health services and decreases health status. People who live in poverty often have a higher incidence of chronic diseases, including mental illnesses such as depression and anxiety. (Brown, 2015) Understanding the disparities that women face is extremely important to society at large because poor health in women often translates into poor health for families, as women are often the ones The Utah Women's health Review 5 6 responsible for meeting the physical and emotional needs of family members (Cawthorne, 2008). In particular, obstetrics providers are in short supply in rural areas, and that lack of access has been linked with poorer health outcomes (Nesbitt et al., 1997). Due to the lack of supply of obstetrics providers, women in rural areas often rely upon family medicine physicians to provide this care (Cohen & Coco, 2009). Access to care in general has been linked with socioeconomic status (Dunlop et al., 2000) and geographic location (Glazier et al., 2004). Aday and Andersen argued that actual use of health services was determined by individual health needs, the predisposition to seek care, and a range of enabling or impeding factors (Aday & Andersen, 1974; Andersen, 1995). It has also been recognized that women live within complex and diverse social, economic, and environmental circumstances that influence options for health behavior and health care (Hankivsky & Christoffersen, 2008; Hankivsky et al., 2010). Disparities in health outcomes among women exist between racial and ethnic groups as well. Women of color fare worse than white women across a broad range of measures in almost every state, and in some states these disparities are quite stark (James et al., 2009). Preventive services such as breast cancer screening are lower in rural areas, and the result is that breast cancer in rural women is often diagnosed at a later stage compared to diagnoses in urban women (Rayman and Edwards, 2010). Lower screening rates may be attributable to lack of insurance, geographic maldistribution of screening facilities, and poor health literacy. Rural women are also less likely to receive preventive health screenings than urban women (Hageman et al., 2010). Disparities in mental health services have resulted in rural residents being far less likely than urban residents to receive mental health treatment (Hoge et al., 2007). A variety of barriers keeps people from seeking and receiving mental health care, including the cost of treatment, lack of awareness of mental illness, not believing that treatment is necessary, lack of time, not knowing where to go for services, and stigma surrounding mental illness (Mulder, 2012). Some of these barriers are am- plified in rural and frontier communities due to the lack of anonymity in these communities (New Freedom Commission on Mental Health, 2004). The distance and time needed to access services, and the fact that rural residents are more likely to be uninsured and poorer than their urban counterparts, contribute to this disparity (Ziller et al., 2003). Conversely, some aspects of living in rural areas may help protect women's mental health. One study showed that women living on farms scored higher than average on mental health assessments (Hillemeier, 2008). This analysis of the health outcomes among women in rural, urban and frontier areas in Utah addresses many of these disparities and the barriers that contribute to them. It also considers chronic conditions as well as access to care and preventive services and the impact of household income on each of these factors. Methods The Utah IBIS-PH Query System (Indicator-Based Information System for Public Health Data Resource) was used to evaluate age-adjusted aggregate data of small health areas from the Utah Behavioral Risk Factor Surveillance System (BRFSS) for fifteen different health outcomes. Data for 13 of the health outcomes that we analyzed were from 2012-2014. Cigarette smoking and physical inactivity data were from 2009 - 2014 due to the small number of survey responses in some areas. Age-adjusted rates, confidence intervals and standard errors for all fifteen health outcomes were calculated in order to compare rates for women in 63 urban, rural and frontier "small health areas." Each small area contains a population ranging from approximately 20,000 to 60,000 persons. These geographic areas are particularly useful for public health assessment in Utah since the designation of each small area is based on specific criteria including population size, political boundaries of cities and towns, and economic similarity. In Utah, urban areas are classified as having more than one hundred people per square mile, rural areas are classified as having six to ninety-nine people per square mile, and frontier areas are The Utah Women's health Review classified as having < 6 people per square mile. Since frontier areas typically are left out of health research, all three classifications are considered. We made the assumption that disparities would exist between rural and frontier areas, just as they do for rural versus urban areas. Seven of the outcomes address access to care and preventive services, while eight of the outcomes represent general physical and mental health including chronic conditions. Age-adjusted rates are a weighted average, with each age-specific rate weighted by the proportion of people in that age group in the U.S. 2000 standard population. Age-adjusted rates control for age effects and allow for better comparability of rates across areas. These rates may also be used to control for age effects when making comparisons across several years of data, as the age distribution of the population changes over time. Confidence intervals were calculated for each of the health outcomes using the Utah IBIS-PH Query System. In this system the confidence factors are obtained by using SAS ® software that requires specification of the percentage of the inverse gamma distribution to be excluded on either end of the distribution (2.5% for a 95% confidence interval), and the two parameters are associated with the distribution function: the mean and the variance. For this reason, it can be assumed that confidence intervals that do not overlap are highly likely to be considered statistically significant. Specific definitions of each health outcome used in the analysis are listed in Table 1. Table 1. Data Definitions Health Outcome Cost as a barrier to care Routine medical checkup No personal doctor Routine dental care Daily fruit consumption Cigarette smoking Mammography screening General health status Physical inactivity Mental health Depression Obesity Diabetes Cancer Asthma Definition Unable to get needed care due to cost Not in the past 12 months No personal doctor or health care provider More than 1 year ago or never Fewer than 2 servings Current smoker Mammography (Women 40+) More than 2 years ago or never Fair or Poor health No leisure time activity Past 30 days - 7 or more days not good Ever been told by a doctor that you have a depressive disorder BMI 30+ (Overweight or obese) Diabetes prevalence - Have diabetes Diagnosed with other cancer besides skin Asthma diagnosed by doctor Adjusted linear regression was run using STATA ® on each health outcome separately, in order to determine the association with household income (scaled per $10,000). Poverty data were obtained from the Utah IBIS-PH Query System BRFSS data for 2015. This analysis is important since the lack of financial stability negatively affects both access to care and health status. People who live in poverty often suffer from higher rates of chronic disease and mental illness. Results of the adjusted linear regression are listed in Table 3. The Utah Women's health Review 7 Results The results of the analysis document compelling evidence of the persistence of health disparities between urban, rural and frontier areas in Utah. Women in rural areas have lower (better) percentages in all eight of the outcomes relating to general physical, mental and chronic conditions. Conversely, women in rural areas have higher (worse) percentages in all seven of the outcomes representing access to care and preventive services. The only outcome that was statistically significantly lower in rural areas was obesity. Depression and obesity percentages were both statistically significantly higher for urban areas than rural areas. Frontier areas had the highest percentages in eleven of the fifteen outcomes, and five of these differences were statistically significant. These five areas include routine medical checkup, daily fruit consumption, smoking, mammography screening and physical inactivity. Table 2 contains the percentages, confidence intervals and standard errors for each health outcome in rural, urban and frontier areas. Table 2. Rural, Urban and Frontier Health Outcomes Rural Urban Health Outcome Cost as a barrier to care 1 No routine medical checkup 1 No personal doctor 1 Routine dental care 1 Daily fruit consumption 1 Cigarette smoking 2 No mammography screening 1 General health 1 Physical inactivity 2 Mental health 1 Depression 1 Obesity 1 Diabetes 1 Cancer 1 8 Asthma 1 Frontier % CI Std Error % CI Std Error % CI Std Error 17.5 (15.9 - 19.1) 4.73 17.2 (16.4 - 18) 2.36 15.8 (13.8 - 18) 6.78 38.4 (36.4 - 40.5) 2.69 37.4 (36.5 - 38) 1.34 41.1* (38.5 - 44.3) 3.57 20.1 (18.4 - 21.8) 4.34 19.5 (18.7 - 20) 2.14 15.1 (13 - 17.5) 7.48 28.6 (26.8 - 30.6) 3.41 27.8 (26.9 - 29) 1.7 30.1 (27.5 - 32.8) 1.7 62.8 (60.5 - 65.1) 3.12 62 (60.6 - 63.1) 1.64 68.5* (65.3 - 71.5) 5 9.2 (8.4 - 10.1) 4.85 8.8 (8.4 - 9) 2.56 12.1* (10.6 - 13.7) 6.5 33.8 (31.2 - 36.5) 4.01 33.5 (32 - 35) 2.23 40.4* (36.7 - 44.2) 4.74 13.2 (11.9 - 14.7) 5.37 13.9 (13.3 - 15) 2.58 15.8 (13.7 - 18.1) 7.13 18.1 (16.6 - 19.6) 4.25 19.5 (18.6 - 20.3) 2.26 22.7* (20.4 - 25.1) 5.3 18.6 (17 - 20.3) 4.47 19.4 (18.6 - 20.2) 2.13 21.3 (18.8 - 23.9) 6.06 25 (23.3 - 26.8) 3.62 27.9* (27 - 29) 1.63 26.9 (24.4 - 29.5) 4.84 22.6* (20.9 - 24.3) 3.86 25.4* (24.5 - 26) 1.88 26.5 (24 - 29.1) 4.95 6.4 5.6 - 7.4) 7.06 7.3 (6.8 - 8) 3.38 7.5 (6.6 - 8.8) 7.78 6.7 (5.9 - 7.7) 6.74 6.8 (6.3 - 7) 3.48 6.9 (5.6 - 8.4) 10.24 9.7 (8.6 - 10.9) 6.21 11.1 (10.5 - 11.8) 3.01 10.4 (8.7 - 12.4) 9.15 BRFSS: 2010-2014 BRFSS: 2009-2014 * Statistically significant 1 2 The Utah Women's health Review Frontier areas had the lowest percentages for cost as a barrier to care and having no personal doctor. This seems to suggest that even though women living in frontier areas do not have as many routine medical checkups or mammography screenings, they are more likely to have a personal doctor and they do not consider cost as a barrier to care as often as women in rural and urban areas might. The percent of women who have had no mammography screening in the past two years or never was highest in frontier areas (40.4%) followed by rural (33.8%) and urban (33.5%). Figure 1 is a map of the percent of women over age 40 who have not had a mammogram in the last 2 years or never. The percent of women who have not had a regular medical checkup in the past twelve months was also highest in frontier areas (41.1%) followed by rural (38.4%) and urban areas (37.4%). Figure 2 shows the percent of women who have not had a routine medical checkup in the past twelve months. The percentage of women with poor mental health was highest in frontier areas (21.3%) followed by urban (19.4%) and rural (18.6%). On the other hand, depression was lowest in rural areas (25%) followed by frontier areas (26.9%) and then urban areas (27.9%). The percentages of obesity, diabetes, cancer and asthma were higher in urban areas than in rural areas. Obesity, diabetes and cancer percentages were the highest in frontier areas but none of them are statistically significantly higher. The percentage of women who use cigarettes was the highest in frontier areas (12.1%), followed by rural areas (9.2%) and then urban areas (8.8%). The percentage of women who use cigarettes in frontier areas was so much higher than in rural areas that the difference was statistically significant. The highest percentage of women with asthma was in urban areas (11.1%), followed by frontier (10.4%) and then rural (9.7%). The higher percentage of women with asthma in the frontier areas than rural areas may be linked to occupational and environThe Utah Women's health Review 9 mental conditions such as dust and agriculture. One of the unexpected findings of the analysis revealed that five of the "small areas" were frequently ranked in the top five unhealthie